The gynecologist needs to take a holistic approach when interacting with the patient and not just view her as requiring medical intervention for a specific presenting problem. Rather she should be perceived as an individual who may have a variety of factors contributing to her health status. The initial approach to the gynecologic patient and the general diagnostic procedures available for the investigation of gynecologic complaints are presented here. Although other aspects of the complete physical examination are left to other texts, concern for the patient’s total health and well-being is mandatory.
THE PERIODIC HEALTH SCREENING EXAMINATION
Part of the physician’s responsibility is to advise patients to have periodic medical evaluations. The frequency of visits varies according to the patient’s age and specific health issues.
Periodic health screening examination helps detect ailments that are especially amenable to early diagnosis and treatment, such as diabetes mellitus; urinary tract infection or tumor; hypertension; malnutrition or obesity; thyroid dysfunction or tumor; and breast, abdominal, or pelvic tumor. These conditions can be detected by a review of systems, with specific questions regarding recent abnormalities or any variation in function. Determination of weight, blood pressure, and urinalysis may reveal variations from the previous examination. An examination of the thyroid gland, breasts, abdomen, and pelvis, including a Papanicolaou (Pap) smear, should then be performed. A rectal examination is recommended as well as testing for occult blood (Hemoccult), sigmoidoscopy, or colonoscopy for patients beginning at age 50 years and continuing until age 75. These guidelines should be modified based on personal risk factors. Patients older than age 40 years should undergo blood test for lipid profile, pelvic ultrasound examination, and mammography, depending on family history. Postmenopausal women with fractures should have a bone density test, and women under age 65 with risk factors for osteoporosis should be screened.
The physician should be concerned about conditions other than purely somatic ones. Unless a patient’s problems require the services of a psychiatrist or some other specialist, the doctor should be prepared to act as a counselor and work with the patient during a mutually agreeable time when it is possible to listen to her problems without being hurried and to give support, counsel, and other forms of assistance as required.
To adequately evaluate the gynecologic patient, it is important to establish a rapport during the history taking. The patient needs to speak freely to an interested listener who does not allow body language or facial expressions to imply disinterest or boredom. One should avoid interrupting the patient, because doing so may obscure important clues or other problems that may have contributed to the reasons for the visit.
The following outline varies from the routine medical history because, in evaluating the gynecologic patient, the problem often can be clarified if the history is obtained in the following order.